A list of the most recent deficiencies for Senior Citizens Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-24 | 2024-01-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | 2023-11-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-15 | 2023-11-16 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-27 | 2023-11-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-27 | 2023-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-27 | 2023-11-15 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-27 | 2023-11-15 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-27 | 2023-11-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-27 | 2023-11-15 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-27 | 2023-11-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-27 | 2023-11-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-27 | 2023-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-27 | 2023-11-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-27 | 2023-11-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-27 | 2023-11-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-27 | 2023-11-15 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-27 | 2023-11-15 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-09-27 | 2023-10-14 | Y |
| Post nurse staffing information every day. | Health | 2023-09-27 | 2023-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-06-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-12 | 2022-06-03 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-12 | 2022-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-03 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-11-07 | 2019-12-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-09 | 2019-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-09 | 2019-11-05 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-10-09 | 2019-11-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-09 | 2019-11-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-09 | 2019-11-05 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-09 | 2019-11-05 | N |
